1. When caring for a patient who has septic shock, which assessment finding is most important for the nurse to report to the care provider?

(a) BP 92/56

2. Skin cool and clammy- means progression

3. Apical pulse 118 beats/min

4. Arterial oxygen saturation 91%

2. Calculate the mean arterial pressure (MAP) in mmHg for a patient with a blood pressure of 84/46mmHg. (Record answer to the nearest whole number)

MAP = SBP + 2 (DBP)/

3

84+2(46)/3=59

3. The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding would indicate the presence of pneumothorax in this client?

(a) A low respiratory rate (b) Diminished breath sounds

3. The presence of a barrel chest-copd

4. A sucking sound at the site of injury-open chest

4. The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which finding?

1. Slow deep respirations

2. Rapid deep respiration

3. Paradoxical respirations

4. Pain, especially with inspiration

5. A client with a chest injury has suffered a flail chest. The nurse assesses the client for which most distinctive sign of flail chest?

1. Cyanosis

2. Hypotension

3. Paradoxical chest movement-hall mark

4. Dyspnea, especially on exhalation

6. A client has been admitted with chest trauma after a motor vehicle crash and has undergone subsequent intubation. The nurse checks the client when the high- pressure alarm on the ventilator sounds and notes that the client has an absence of breath sounds in the right upper lobe of the lung. The nurse immediately assesses for other signs of which condition?

1. Right pneumothorax